Eligibility Requirements

The Shifa Free Clinic provides Gynecological care to eligible women at no cost.

Eligibility checks are done on Monday by appointment from 9 a.m. to 1 p.m.

You will have to complete the new patient clinic application (attached below) and meet our eligibility requirements prior to scheduling an appointment with a doctor.

Eligibility Requirements (you must):

Be between the ages 19 - 64

Have no health insurance

Have an income level that falls within 250% of the Federal Poverty Level based on the number of people in your household

After eligibility requirements have been met, a patient will be issued a Shifa Clinic eligibility card which is good for one year. Patients must re-qualify every year.

Required Documents

1. Identification Documents: Any one of the following

Driver's license

DMV ID card

Passport

Valid Green Card

2. Proof of Income for each working member of your household:

(Choose documents as applicable)

If patient is employed, then we need a copy of their paycheck stub (last 4 weeks) or letter from employer.

If patient is self employed, then we need copy of their most recent tax return.

If patient is unemployed, then we need letter of support from whomever is supporting them. For example, information about the person who is feeding and giving shelter them. We need that information from the person him/herself. See attached letter of support form.

Child support, Alimony, Food Stamps, SSI

Chart for income guidelines

House hold size

Weekly income

Monthly income

Annual

1

$552

$2394

$28,725

2

$746

$3231

$38,775

3

$940

$4069

$48,825

4

$1132

$4906

$58,875

5

$1325

$5744

$68,925

6

$1519

$6581

$78,975

Each additional person

$193

$838

$10,050

If you are unable to come in on Monday to complete the clinic application, you can print the new patient clinic application attached below, and either mail or fax the clinic application and all other required documents to us. Once all the required documents have been received you will receive a phone call from the clinic regarding your eligibility and to schedule an appointment to see a doctor.